Foundations and Adult Health Nursing Study Guide Answers

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A patient undergoing mechanical ventilation in the ICU develops ventilator-associated pneumonia (VAP) caused by multidrug-resistant organisms (MDROs). What intervention should the healthcare team prioritize to manage the patient's infection?

  • A. Administer combination antibiotic therapy targeting MDROs.
  • B. Perform bronchoalveolar lavage for diagnostic purposes.
  • C. Implement strict isolation precautions to prevent transmission.
  • D. Recommend prophylactic antifungal therapy to prevent candidiasis.
Correct Answer: A

Rationale: The most appropriate intervention for managing ventilator-associated pneumonia (VAP) caused by multidrug-resistant organisms (MDROs) is to administer combination antibiotic therapy targeting the specific resistant pathogens identified in the patient's culture results. MDROs are often resistant to multiple antibiotics, so combination therapy is required to maximize the chances of effectively treating the infection. Identifying the specific pathogens causing the VAP through cultures is crucial in tailoring the antibiotic therapy to target these organisms effectively. Implementing appropriate antibiotic therapy promptly is essential to improve outcomes and prevent further complications in patients with VAP caused by MDROs. Option A is the priority intervention in this case to address the multidrug-resistant nature of the infection and provide targeted treatment for the patient.

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A patient with obstructive sleep apnea (OSA) presents with excessive daytime sleepiness, loud snoring, and witnessed apneic episodes during sleep. Which of the following interventions is most appropriate for managing OSA and improving symptoms?

  • A. Weight loss and lifestyle modifications
  • B. Continuous positive airway pressure (CPAP) therapy
  • C. Oral appliance therapy
  • D. Surgical uvulopalatopharyngoplasty (UPPP)
Correct Answer: B

Rationale: CPAP therapy is considered the gold standard treatment for obstructive sleep apnea (OSA) and is the most appropriate intervention for managing OSA and improving symptoms. CPAP therapy involves using a machine that delivers a continuous flow of air through a mask worn over the nose or mouth during sleep. This air pressure helps keep the airway open, preventing the collapse that causes apneas and snoring during sleep.

A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the:

  • A. Durable power of attorney
  • B. Living will
  • C. Informed consent
  • D. Advance directives
Correct Answer: B

Rationale: A living will is a legal document that allows an individual to express their wishes regarding medical treatment in the event they become unable to make decisions. It specifically outlines the medical treatments a person chooses to refuse or accept under certain circumstances. It is important to differentiate a living will from a durable power of attorney, which designates someone to make healthcare decisions on behalf of the individual when they are unable to do so, and advance directives, which encompass both a living will and a durable power of attorney for healthcare. The living will serves as a guide for healthcare professionals and family members to honor the individual's preferences for medical care.

Before finishing the check up, which of the following principles is NOT included among the principles of guidance in handling Richard?

  • A. Controlling temper tantrums
  • B. Basing her expectations within the child's limitations.
  • C. Acceptance of masturbation as a normal phenomenon to be discouraged in public.
  • D. Reinforcing the correct use of language.
Correct Answer: D

Rationale: The principles of guidance in handling Richard involve understanding and addressing the behaviors and needs of the child, such as controlling temper tantrums, basing expectations within the child's limitations, and acceptance of certain behaviors like masturbation as normal but to be discouraged in public. However, reinforcing the correct use of language is not typically included as a principle specifically in handling Richard. Therefore, this choice is NOT included among the principles of guidance in this context.

An infant's current weight indicates that the maximum safe dose of Tylenol is 30 mg by mouth. The physician orders 65 mg to be given, the pharmacist is responsible for filling the medication order, and the nurse administers Tylenol 65 mg. Who is legally responsible in the event that the infant has a toxic reaction to the medication?

  • A. nurse
  • B. physician
  • C. pharmacist
  • D. pharmacist and physician
Correct Answer: C

Rationale: The pharmacist is legally responsible in this situation because they are the healthcare professional authorized to dispense medications according to the physician's order. In this case, the physician ordered a dose higher than the maximum safe dose recommended based on the infant's current weight. While the nurse administers the medication, the pharmacist has the responsibility to ensure that the correct dose is dispensed and to alert the physician if there is a discrepancy in the order. If the pharmacist dispensed the incorrect dose without verifying with the physician, they would bear legal responsibility for any adverse effects resulting from the medication error.

Some postpartum mothers will experience difficulty voiding because of the edema and trauma of the perineum. Which PRIORITY nursing measures stimulate the sensation of voiding?

  • A. Encouraging her to void.
  • B. Running water in the sink or shower.
  • C. Helping the mother into the shower.
  • D. providing cold tea or fluids of choice.
Correct Answer: B

Rationale: Running water in the sink or shower is a priority nursing measure to stimulate the sensation of voiding in postpartum mothers experiencing difficulty due to edema and trauma of the perineum. The sound and sight of running water can help relax the pelvic floor muscles and trigger the urge to void. This technique is commonly used in clinical practice to facilitate voiding and prevent urinary retention in postpartum women.

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